Those
of us who provide medical care for immigrants and refugees are familiar
with their inevitable decision to return home for a visit. For many
this is a momentous return. They left in terror, to return in safety for
a long-imagined reunion. Now years have passed, many friends and family
members have died, others have grown up, or grown old, and there are
new family members to meet. I have had patients who returned home to
Laos, Cambodia, or China for the first time after decades in exile. The
excitement of return is overwhelming; to honor the dead, to see
childhood landscapes one last time, to eat foods they have missed for
years, to sit with a dying sibling in their illness. The exposures many
risk upon return are sometimes minimized. Patients may shrug and say
they lived there for years and not realize that now 20 years later they
have congestive heart failure, breast cancer, and diabetes, and are
elderly and cannot tolerate the insults to their immune system they
might have weathered in their youth. In addition whatever residual
immunity they had to endemic pathogens has waned in the intervening
years. Others will want whatever treatment they can get but not realize
the expenses may not be covered by Medicaid or their insurance.

Photo By: Clare McLean/UW Medicine

Public Health - Seattle & King County (PHSKC) provides useful tips as you discuss issues with traveling patients.
These tips (see below) are based on the CDC’s Health information for international
travel including detailed guidelines on pre-travel counseling
specifically for persons visiting friends and relatives (VFRs). The
decisions to immunize, prophylax, or treat when symptoms arise are a
careful calculation based on the duration of the trip, geographic areas
and the seasonal prevalence of disease, the urban, rural, or sylvan
settings to be visited, and the condition and co-morbidities of the
traveler. I would add a few caveats to the guidelines to discuss during
the conversation with patients.

Calculate the duration of the
trip and the actual percentage of time exposure to mosquito vectors of
dengue and malaria may occur. This is where a decision to treat symptoms
as they arise vs. take malaria prophylaxis will be decided. The risk of
side-effects from mefloquin, or even doxycycline are not insignificant
and have to be weighed.

Many devout and / or elderly patients
are engaged in religious pilgrimages. I recently had several patients
undertake a pilgrimage to the key sites of the Buddha's life: birth,
enlightenment, and death. Trips to Saudi Arabia for the Haj, or to Holy
sites in Ethiopia are also familiar. At these times there may be special
considerations around crowding and the need for meningococcal vaccine
as for the Haj, or for Yellow Fever if the trip itinerary includes a
country where the disease is endemic.

Unlike tourism which is
usually a month or less, a trip home after years away may take 3-6
months. In these cases patients with chronic illnesses may decompensate
if they do not plan a means to assure they have a steady supply of
their chronic medications. This needs to be addressed and arranged in
advance.

For individuals who are PPD negative or quantiferon negative the
trip home may be another exposure to TB and require a reminder to
re-screen after they have been back in the U.S. a few months. Similar
arguments can be made for HIV if that is a reasonable concern in the
traveler.

The biggest risk to health may not be infectious
disease but motor vehicle accidents and traffic in settings where there
are no emergency services. The recent pilgrims to India I mentioned were
involved in a serious bus accident. Others have been pushed into, or
killed by erratic traffic. A thoughtful reminder of these mundane risks
may address the most real threat faced daily.

Finally, for
many the emotional jubilation of return can be followed by renewed PTSD
or depression. Screening again after reentry can be useful.

In
any case, this is not adventure travel or tourism, but a trip home,
often to remote locations for prolonged periods and the traveler must be
well prepared.

Pre-travel counseling for VFRs:

Persons visiting friends and relatives
(VFRs) may be more likely than other travelers to stay in destinations that put
them at greater risk of acquiring travel-related diseases, and less likely to
take recommended preventive measures and precautions. In fact, according to the
Centers for Disease Control (CDC),VFRs experience more malaria, typhoid fever, cholera,
tuberculosis, hepatitis A, and sexually transmitted diseases than other groups
of international travelers. For example, over the past 3 years, nearly
two-thirds of the malaria cases reported in King County occurred in people
traveling abroad to visit friends or relatives, especially in Africa and Asia.

The CDC’s Health information for international travel includes
detailed guidelines on pre-travel counseling specifically for VFRs, with tips
including the following:

Many young adults from developing countries may
still be susceptible to hepatitis A; consider pre-travel serologies for both hepatitis A and hepatitis B in previously
unvaccinated patients.

Recommend that VFRs purchase malaria
prophylaxis before traveling and begin taking them before departure if appropriate. Drugs that may be available at their travel
destination may no longer be effective against malaria due to poor quality, counterfeit, or high levels
of resistance.

For those at high risk of traveler’s diarrhea
from locally served foods at homes and street stalls, simplify empiric treatment by using single dose meds such as azithromycin or
ciprofloxacin.

Consider varicella vaccination for adult
immigrants traveling overseas, especially to South or Southeast Asia and Latin America. Varicella infection occurs at older ages in
tropical regions, and deaths and complications are more common in infected adults than children.

Because many VFRs may have already had
previous exposure to dengue fever, protective measures to avoid mosquito bites are essential to reduce risk of dengue
hemorrhagic fever or dengue shock syndrome. Mosquito precautions also reduce the risk of serious mosquito-borne
infections including malaria, yellow fever, and Japanese encephalitis.